Male 76, failed back surgery, central obesity, etc.

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Hi Everybody!

 

I am starting with the pain and deficiency on this patient. First

treatment was LI 4, 11; L 7; St 36; Sp 6; Ashi on the back of the neck

and electro between Sp 6 and St 36 on the left. He initially could not

feel the needles in his left leg so I hooked up the stim machine. Half

way through the 20 minute retention he became uncomfortable with the

stim so I removed it and the needles on the left leg as well. The right

leg he felt the needles normally. He also had a sharp pain in his left

ankle near UB 59, when I pressed on it with my finger it went away but I

noticed that the pressure left a deep pit - pitting edema. The treatment

left him feeling about the same, which is unusual - patients usually say

they feel better.

 

I recommended Restore Nex (complete info below) which he took home to

try. His next appointment is Monday. I will put him on his side and do

Ashi on his back and neck on Monday, unless someone has a better idea.

 

Nearly all of his weight is in his belly, the rest of him is skinny.

Yes, he is diabetic.

 

Patient Medical History: DOB *-**-30, 76 years old.

 

Patient: male Record 1-24-6

 

Patient Number: **********

 

What is your major complaint? Low back pain radiating to ventral side of

left leg " sciatica " , getting worse.

How long have you had this condition? Sciatica for years, pain when

sitting down.

What treatments or remedies have you tried for this condition? Surgery

on cervical and lumbar.

 

Have you seen a Western Doctor for this condition? Yes.

Have you seen a Chiropractor for this condition? No.

Have you ever had scarlet fever? No.

Have you ever had diphtheria? Yes.

Have you ever had rheumatic fever? No.

Have you ever had chronic or frequent colds? No.

Have you ever had sinusitis? No.

Have you ever had tuberculosis? No.

Have you ever had a heart murmur? Yes.

Have you ever had a heart attack? Yes, 3 or 4 times - and open heart

surgery.

Have you ever had a heart condition? Yes.

Have you ever had stomach, liver or intestinal trouble? Yes. gastroparesis.

Have you ever had gallbladder trouble or gallstones? Yes, removed in 1996.

Have you ever had jaundice? No.

Have you ever had a reaction to serum, drug or medicine? Yes, Mirapex

gave him red-man syndrome.

Have you ever had a tumor, growth, cyst or cancer? No.

Have you ever had piles or rectal disease? Yes, surgery for piles.

Have you ever had a kidney stone or blood in your urine? No.

Have you ever had sugar or albumin in your urine? Yes, diabetic.

Have you ever had venereal disease? No.

Have you ever had any drug or narcotic habit? No.

Have you ever had an excessive drinking habit? No.

Have you ever had to wear a neck or back brace? Yes, wear one now.

Have you ever had exposure to tuberculosis? No.

Have you ever had to wear eyeglasses? Yes.

Have you ever had eye trouble? No.

Have you ever had ear, nose or throat trouble? Yes, earaches as a youth,

over by age 23. Army surgeons drained his ears 5 or 6 times.

 

Have you ever had or do you now have shortness of breath? Frequent, with

exertion.

Have you ever had or do you now have swollen ankles? Seldom, take Bumex

for this.

Have you ever had or do you now have high blood pressure? No, controlled

by Licinopril.

Have you ever had or do you now have a rapid heartbeat? No.

Have you ever had or do you now have dizziness? No.

Have you ever had or do you now have fainting spells? No.

Have you ever had or do you now have chest pain or pressure? Seldom,

with headaches.

Have you ever had or do you now have leg cramps? Seldom, not lately.

Have you ever had or do you now have a cough? Seldom.

Have you ever coughed up blood or do you now? No.

Have you ever had or do you now have hoarseness? No.

Have you ever had or do you now have sore throats? No.

Have you ever had or do you now have hay fever? Seldom.

Have you ever had or do you now have nosebleeds? Seldom, Frequent as a

child until 15 or 16.

Have you ever had or do you now have asthmatic wheezing? No.

Have you ever had or do you now have pneumonia? Seldom now, every year

in Army.

Have you ever had or do you now have indigestion? Seldom, but has

gastroparesis.

Have you ever had or do you now have abdominal pain or cramps? No, takes

Zelnorm to control.

Have you ever had or do you now have constipation? Frequent, takes Miralax.

Have you ever had or do you now have diarrhea? No.

Have you ever had or do you now have blood in your bowel movement? Seldom.

Have you ever had or do you now have a black bowel movement? Seldom.

Have you ever had or do you now have increased appetite? Frequent.

Have you ever had or do you now have increased thirst? Seldom, due to

diabetes.

Have you ever had or do you now have decreased appetite? No.

Have you ever had or do you now have nausea and vomiting? Seldom,

gastroparesis.

Have you ever had or do you now have difficulty swallowing? No.

Have you ever had or do you now have skin ulceration? No.

Have you ever had or do you now have itching? No

Have you ever had or do you now have a rash? No.

Have you ever had or do you now have back pain? Frequent, excruciating.

Always at least a 4, spikes to 9.

Have you ever had or do you now have frequent urination? Frequent.

 

(male only section)

Have you ever had or do you now have pain in the testicles? No.

Have you ever had or do you now have bloody or other discharge from your

penis? No,

Have you ever had or do you now have loss of sexual potency? Frequent,

Viagra didn't work.

(end of male only section)

 

Have you ever had or do you now have arthritis? Frequent.

Have you ever had or do you now have muscle pain or cramps? Frequent.

Have you ever had or do you now have painful joints? Frequent.

Have you ever had or do you now have lameness? Frequent, can only take

10 steps and has to rest.

Have you ever had or do you now have backaches? Frequent back and leg pain.

Have you ever had or do you now have weakness? Frequent.

Have you ever had or do you now have fever? No.

Have you ever had or do you now have chills? Frequent in winter.

Have you ever had or do you now have night sweats? No.

Have you ever had or do you now have headaches? No.

Have you ever had or do you now have insomnia? Frequent.

Have you ever had or do you now have nervousness? Seldom.

Have you ever had or do you now have irritability? Seldom.

Have you ever had or do you now have morning tiredness? No.

Have you ever had or do you now have easy fatigability? No, pain stops

him, not fatigue.

 

Have you ever been refused employment because of your health? No.

Why were you refused employment because of your health?

 

Have you ever been denied life insurance because of your health? No.

Why were you refused life insurance because of your health?

 

Have you ever been rejected for or discharged from military service

because of physical, mental or other reasons? No.

 

Do you smoke? No. Quit 30 years ago.

What do you smoke?

How much do you smoke? Used to smoke 3 packs a day, which is about the

practical maximum for one cigarette at a time.

How long have you smoked?

 

Do you have or have you had weight loss recently? Yes.

Do you have or have you had weight gain recently? No.

How much have you lost or gained? 6 pounds since he returned from the

cruise on the 9th.

5' 5 3/4 " , 209 lbs.

 

Do you have or have you had a memory defect recently? No.

Do you have or have you had a change in your handwriting recently? No.

Do you have or have you had difficulty walking in the dark recently? No.

Do you have or have you had balance problems recently? No.

Do you have or have you had numbness or tingling in the extremities

recently? Yes

Do you have or have you had hearing loss recently? Yes.

Do you have or have you had ringing ears recently? No.

Do you have or have you had a change in your vision recently ? Yes,

gradually.

Do you have or have you had an ear ache recently? No.

Do you have or have you had running ears recently? No.

Do you have or have you had new skin growths recently? Yes.

Do you have or have you had a change in the color of your skin recently?

Yes, prone to damage.

Do you have or have you had a tendency to bruise easily recently? Yes,

purpura.

Do you have or have you had athlete's foot recently? No.

Do you have or have you had heat intolerance recently? No.

Do you have or have you had cold intolerance recently? Yes.

Do you have or have you had a change in your shoe or hat size recently? No.

Do you have or have you had lymph node enlargement recently? No.

Do you have or have you had kidney stones recently? No.

 

Do you have other items of physical fitness you want to mention? No.

What are the other items of physical fitness you want to mention?

 

Is there a history of tuberculosis in your family? No.

Who had tuberculosis in your family?

 

Is there a history of diabetes in your family? Yes, he is diabetic.

Who had diabetes in your family?

 

Is there a history of cancer in your family? No.

Who had cancer in your family?

 

Is there a history of gout in your family? No.

Who had gout in your family?

 

Is there a history of heart trouble in your family? Yes, mother and father.

Who had heart trouble in your family?

 

Is there a history of stroke in your family? No.

Who had a stroke in your family?

 

Is there a history of high blood pressure in your family? Yes, father.

Who had high blood pressure in your family?

 

 

Is there a history of asthma, hay fever or hives in your family? No.

Who had asthma, hay fever or hives in your family?

 

Is there a history of glaucoma in your family? No.

Who had glaucoma in your family?

 

What medications do you currently take? Insulin, Zelnorm, Magnesium,

Lisinopril, Requip, Actos, Flomax, Erythomicin,Aspirin, Co Q, Miralax,

Choles-plus, Multivitamin 1x day, Acidophillus 2x day, Percocet, Ambien,

Folic Acid, Aciphex, Clonazepam.

 

Have you been hospitalized or treated in the past year for what you

would consider a significant condition? Yes, observation for

endocarditis, Feb 2005.

 

Are there other factors in your physical condition not already covered

that you have questions about? Peripheral Neuropathy.

 

Please list all operations you may have had, and your age when you had them.

Eardrum piercings c. 1954

Bone Spur 1957

Open Heart Surgery 1988

Gallbladder 1998

Rotator cuff 1998, 2000

Toe straightened 2001

Cataracts 2001, 2003

Eyelid 2004

Laminectomy 2004, 2005

End of Medical History portion.

 

Four Pillar Examination:

 

Observe:

 

Unhealthy complexion. Yes. (no spirit)

Red color (may indicate Inflammation, fever or infection) Purpura as well.

 

Five Element Body types: No clear correlation.

 

Fat body. Yes. (Central Obesity in Western Medicine terms. Damp Phlegm,

Spleen Qi and/or Kidney Yang deficiency.)

The eyes have glitter and reveal inner vitality. Yes.

Loose teeth, kidney essence deficient. Has upper denture and lower partial.

Observe the gums. Has had teeth lost due to gingivitis.

Red face, heat in the blood.

Healthy color around wrists and ankles. No.

Dry and shriveled around wrists and ankles. Yes.. (Blood or Yin

Deficiency maybe Lung, Kidney, Liver; Blood Stasis or Painful

Obstruction Syndrome)

Pale nails. Yes. (Pale-white: Liver and Spleen Blood deficiency;

Dull-white: Spleen and Kidney Yang deficiency or sudden loss of Body

Fluids as in profuse vomiting, diarrhea or sweating) Couldn't decide if

pale white or dull white.

Observe the Thenar Eminence. (Shows the state of the Stomach)

Bluish - Cold.

 

Tongue spirit: Like a fresh piece of meat - good spirit.

Tongue color.

Purple on the sides: Liver Blood Stasis.

Tongue coating.

Thin with root: Healthy Stomach Qi.

Tongue patterns:

General Blood Deficient: Pale and slight dryness.

 

Inquire:

 

Time of day when the head aches. Night while asleep, slight headache -

Blood Stasis.

Location of the headache.

Forehead - ?Bright Yang? Stomach Heat or Blood deficient.

Character of the headache pain: Dull - deficient.

Pain that is diminished by heat. Yes. (cold)

Pain that is diminished by cold. Yes. (heat)

Pain that is relieved by touch or pressure. Yes. (deficient)

Clear Urine. Yes (Cold in the Bladder or Kidney Yang deficiency)

Infrequent, dry hard stool. Yes. (Accumulation of Heat or Deficiency of

Qi and Blood)

Stool dry at first, then wet. Yes. (Liver Qi Stagnation Invading the

Spleen, maybe with Dampness, Severe Spleen Qi Deficiency)

Undigested food in the stool. Yes. (Spleen Deficiency)

Thirst, appetite and tastes.

Not able to fall asleep. Yes. (Blood or Yin deficiency of Heart, Spleen,

Liver) He has a rebreather machine that helps, may have sleep apnea.

Wake up early and not able to fall asleep again. Yes. (Yin deficiency

with empty Heat)

Change in sinews, such as weak or stiff. No.

Change in blood vessels, (but not) hard & wiry pulse. Yes. (stagnation

in the body, usually related to a disharmony that impairs the flowing

and spreading functions of the Liver and Gall Bladder)

Change in the skin, such as flaccid skin. Yes.

Throws off the blanket at night. Yes, used to, but not much any more.

(excess heat maybe liver or heart)

 

Listen & smell:

 

(no remarkable sounds or smells)

 

Palpate:

 

Systolic blood pressure (Optimal <120; Normal <130; High Normal <139;

Stage 1, 140) 141

Diastolic blood pressure (Optimal <80) 64

Heart rate. 60

Hidden pulse is an extreme form of the sinking pulse. Yes. (Deficient

Yang if weak. If strong, Deficient Cold obstructing the meridians)

Hollow pulse, like the stem of a green onion, solid on the outside but

completely empty, often a floating pulse. Yes. (Deficient Blood, often

seen after great loss of Blood) Pulse is felt at only one position,

close to the wrist bone, but not quite " distal position " .

 

Flaccidness along the channel or channels. Yes . (deficient Qi and Blood)

Which channel or channels are flaccid? All.

 

Dry skin. Yes. (deficiency of liver blood)

Withered skin. Yes. (fluids are exhausted)

 

Summary: Unhealthy complexion (no spirit); Red color (may indicate

Inflammation, fever or infection); Purpura as well; Central Obesity;

(Damp Phlegm, Spleen Qi and/or Kidney Yang deficiency.) BUT The eyes

have glitter and reveal inner vitality. Loose teeth, kidney essence

deficient. (Has upper denture and lower partial.) Observe the gums. Has

had teeth lost due to gingivitis; Red face, heat in the blood; Unhealthy

color around wrists and ankles; Dry and shriveled around wrists and

ankles. (Blood or Yin Deficiency maybe Lung, Kidney, Liver; Blood Stasis

or Painful Obstruction Syndrome) Pale nails. Yes. (Pale-white: Liver and

Spleen Blood deficiency; Dull-white: Spleen and Kidney Yang deficiency

or sudden loss of Body Fluids as in profuse vomiting, diarrhea or

sweating) Couldn't decide if pale white or dull white. Bluish Thenar

Eminence. (Shows the state of the Stomach) - Cold in the stomach, would

have expected heat. Tongue spirit: Like a fresh piece of meat - good

spirit; Tongue color: Purple on the sides (pale in the center): Liver

Blood Stasis; Tongue coating; Thin with root: Healthy Stomach Qi; Tongue

patterns: General Blood Deficient: Pale and slight dryness. Time of day

when the head aches. Night while asleep, slight headache - Blood Stasis;

Location of the headache, Forehead - ?Bright Yang? Stomach Heat or Blood

deficient; Character of the headache pain: Dull - deficient; Pain that

is diminished by heat. Yes. (cold); Pain that is diminished by cold.

Yes. (heat) Pain that is relieved by touch or pressure. Yes.

(deficient); Clear Urine. Yes (Cold in the Bladder or Kidney Yang

deficiency); Infrequent, dry hard stool. Yes. (Accumulation of Heat or

Deficiency of Qi and Blood); Stool dry at first, then wet. Yes. (Liver

Qi Stagnation Invading the Spleen, maybe with Dampness, Severe Spleen Qi

Deficiency); Undigested food in the stool. Yes. (Spleen Deficiency) Not

able to fall asleep. Yes. (Blood or Yin deficiency of Heart, Spleen,

Liver) He has a rebreather machine that helps, may have sleep apnea.

Wake up early and not able to fall asleep again. Yes. (Yin deficiency

with empty Heat) Change in blood vessels, (but not) hard & wiry pulse.

Yes. (stagnation in the body, usually related to a disharmony that

impairs the flowing and spreading functions of the Liver and Gall

Bladder) Change in the skin, such as flaccid skin. Yes. Throws off the

blanket at night. Yes, used to, but not much any more. (excess heat

maybe liver or heart); Systolic blood pressure (Optimal <120; Normal

<130; High Normal <139; Stage 1, 140) 141; Diastolic blood pressure

(Optimal <80) 64 Heart rate. 60; Hidden pulse is an extreme form of the

sinking pulse. Yes. (Deficient Yang if weak. If strong, Deficient Cold

obstructing the meridians); Hollow pulse, like the stem of a green

onion, solid on the outside but completely empty, often a floating

pulse. Yes. (Deficient Blood, often seen after great loss of Blood)

Pulse is felt at only one position, close to the wrist bone, but not

quite " distal position " ; Flaccidness along the channel or channels. Yes.

(deficient Qi and Blood); Which channel or channels are flaccid? All.

 

Dry skin. Yes. (deficiency of liver blood)

Withered skin. Yes. (fluids are exhausted)

 

Acupuncture impression: No spirit; Damp Phlegm, Spleen Qi and/or Kidney

Yang deficiency; Kidney essence deficient; Blood or Yin Deficiency

maybe Lung, Kidney, Liver; Blood Stasis or Painful Obstruction Syndrome;

Pale nails indicate some kind of deficiency; Cold in the stomach, would

have expected heat; Tongue shows good spirit, Liver Blood Stasis,

healthy Stomach qi, but General Blood Deficient: Pale and slight

dryness. Head aches at night while asleep, slight headache - Blood

Stasis; Forehead - ?Bright Yang? Stomach Heat or Blood deficient; Dull -

deficient; diminished by heat, (cold); diminished by cold, (heat); Pain

that is relieved by touch or pressure, (deficient); Clear Urine, (Cold

in the Bladder or Kidney Yang deficiency); Infrequent, dry hard stool,

(Accumulation of Heat or Deficiency of Qi and Blood); Stool dry at

first, then wet, (Liver Qi Stagnation Invading the Spleen, maybe with

Dampness, Severe Spleen Qi Deficiency); Undigested food in the stool,

(Spleen Deficiency) Not able to fall asleep, (Blood or Yin deficiency of

Heart, Spleen, Liver) He has a rebreather machine that helps, may have

sleep apnea. Wake up early and not able to fall asleep again, (Yin

deficiency with empty Heat) Change in blood vessels, (but not) hard &

wiry pulse, (stagnation in the body, usually related to a disharmony

that impairs the flowing and spreading functions of the Liver and Gall

Bladder) Change in the skin, such as flaccid skin. Systolic blood

pressure Stage 1, 141; Diastolic blood pressure (Optimal <80) 64. Heart

rate. 60; Hidden pulse is an extreme form of the sinking pulse,

(Deficient Yang if weak) Hollow pulse, like the stem of a green onion,

solid on the outside but completely empty, often a floating pulse

(Deficient Blood, often seen after great loss of Blood) Pulse is felt at

only one position, close to the wrist bone, but not quite " distal

position " ; Flaccidness along the channel or channels, (deficient Qi and

Blood); All channel or channels are flaccid. Pretty much everything

except the tongue is slowed down or deficient. Skin is warm, however.

Noticed pitting edema during treatment, had not been noted during

examination.

 

Treatment principle: Relieve pain, Tonify deficiency.

 

Possible Points: LI 4, 11; L 7; St 36; Sp 6 ASHI

 

Herbal Pills: Restore Nex Tieh Shang Wan (patent, Tianjin Medicine &

Health Products Importing and Exporting Corp.), Liu Wei Di Huang Wan,

possibly others.

 

Regards,

 

Pete